He was a patient in a psychiatric ward at Epsom Hospital when he fell from a tall chimney at the hospital site on May 9 last year.

The care he was receiving at the time was provided by Surrey and Borders Partnership NHS Foundation Trust (SABP), which runs mental health units including the Elgar and Fenby wards.

Representing Mr Withers' family, counsel Christopher Walker explained they had questions they wanted answered about the care Mr Withers received from SABP.

"There are concerns as to the level of observations and supervisions throughout the time," Mr Walker told the hearing.

He requested a plan and photographs of the hospital be made available, including the wards, courtyard and chimney and the distances between them.

Eyewitnesses

Also at the pre-inquest review were relatives of Mr Withers, representatives from SABP and a legal representative for the Health and Safety Executive.

The court heard that work was being carried out on the chimney by Chimney Maintenance Limited, but surveying work had finished therefore the company would not be called to the full inquest.

However, it was ruled that Epsom and St Helier University Hospitals NHS Trust would be contacted as an interested party.

The hearing was told there were a number of witnesses to the incident, all with different accounts of how Mr Withers came to fall to his death.

Coroner Alison Hewitt said: “I will need to have an idea whether he fell from the chimney, whether that was accurate, or whether there was any intention behind his part.

“There were quite a lot of eyewitnesses to the event and a number of officers, security staff and paramedics.

“The language used by the witnesses is to how it was that Adam came to fall from the chimney.

"Some people speak of falling, some speak of jumping, some speak of losing foothold.

“[It will need to be clear] whether the language was used accurately or just general language, not necessarily to convey precisely what accurately happened. Whether it's well founded or not well founded view.”

The full inquest proceedings have been scheduled to begin in early January next year.